Assessing Healthcare Compliance Gaps
Assessing healthcare compliance gaps can be challenging due to first having to identify which healthcare regulations and standards an organization is required to comply with before it is possible to compare the required state of compliance with the existing state of compliance in order to identify where gaps exist.
Organizations in the healthcare industry have to comply with many different federal, state, and industry laws. They may also choose to adopt voluntary standards to maintain a professional accreditation or to demonstrate a good faith effort to be compliant. Due to the number of laws, standards, and other regulations, there are many examples of when compliant efforts can conflict with each other or duplicate each other.
The number of conflicts and duplications can make assessing healthcare compliance gaps challenging. In addition, one of the most important laws affecting healthcare compliance – HIPAA – includes a clause that permits a “flexibility of approach” when deciding which security measures to implement. This clause could exempt an organization from complying with many of the compliance requirements on the grounds of cost.
How to Overcome Healthcare Compliance Challenges
The first stage in overcoming healthcare compliance challenges is to identify duplications. For example, OSHA Standard §1910.39 and CMS’ Emergency Preparedness Rule §485.625(d)(1) both require healthcare organizations to develop a fire prevention plan and train members of the workforce on the plan. This will likely also be a requirement of a local Fire Code. By complying with one standard, an organization will be complying with all three standards.
Thereafter, it is possible to further reduce the challenge of assessing healthcare compliance gaps by identifying when one standard preempts another, or when the organization is exempted from complying with a state law (i.e., the Virginia Consumer Data Protection Act) because it qualifies as a covered entity or business associate under HIPAA. (Note: some state privacy laws do not exempt organizations from complying with the state’s breach notification requirements).
Once all the duplications, preempted standards, and exemptions have been removed – and any compliance obligations considered to be unreasonable or inappropriate under HIPAA’s “flexibility of approach” clause – organizations should be left with a compliance “target” against which to compare their existing state of compliance. This process – although potentially longwinded – will enable organizations to accurately assess healthcare compliance gaps.
Using Software for Assessing Healthcare Compliance Gaps
As an alternative to manually identifying duplications, preempted standards, and exemptions, it is possible to use software for assessing healthcare compliance gaps. Healthcare compliance software can be customized with the laws, regulations, and standards an organization is required to comply with, and produce compliance checklists against which organizations can accurately assess healthcare compliance gaps.
Further benefits of healthcare compliance software include that the software automatically updates whenever new applicable laws, regulations, or standards are published (or amendments to existing laws are published), produces new checklists for assessing healthcare compliance gaps, and alerts organizations to workforce refresher training requirements when necessary. The software should also be able to support incident response and compliance with documentation requirements.
Using software of this nature gives organizations an on-demand holistic view of their compliance profile and further demonstrates a good faith effort to be compliant. Organizations finding it challenging to compare their existing state of compliance against the required state of compliance are advised to speak with a compliance software vendors to organize a demo of the software and evaluate its capabilities against their compliance requirements.
